Basic Information
| Provider Information | |||||||||
| NPI: | 1700113743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINDSFATER | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2930 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806201011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703539403 | ||||||||
| FaxNumber: | 9703539906 | ||||||||
| Practice Location | |||||||||
| Address1: | 1006 A ST | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806312021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703520048 | ||||||||
| FaxNumber: | 9703521120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2009 | ||||||||
| LastUpdateDate: | 01/21/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 9661 | CO | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 04885562 | 05 | CO | MEDICAID |